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National Briefing WebinarMarci Nielsen, PhD, MPH

February 11, 2016

AGENDA

• PCPCC: – Who we are & what we

do

• 2015 Annual Evidence Report: – What we studied & what

we learned

• Paying for Value– Where delivery reform

meets payment reform

– What’s Next?

• Q & A2

Patient-Centered Primary Care (PCPCC) Unifying for a better health system - by better investing in patient-

centered primary care

PAYERS:

Employees,Employers,Health plans,Government,Policymakers

PUBLIC:Patients,Families,Caregivers,ConsumersCommunities

PROVIDERS: Primary care team, medical neighborhood, ACOs, integrated care3

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Co-ChairsHonorable Joe Courtney (D-CT)Honorable David Rouzer (R-NC)

Capitol Hill Briefing hosted by: The Primary Care Caucus

Section One: A CHANGING POLICY LANDSCAPE

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#PCMHEvidence

AUTHORSMarci Nielsen, PhD, MPH Chief Executive Officer, PCPCC

Lisabeth Buelt, MPH• Policy and Research Manager,

PCPCC

Kavita Patel, MD, MS• Nonresident Senior Fellow,

Economic Studies, The Brookings Institution

Len M. Nichols, PhD, MS, MA• Director, Center for Health Policy

Research and Ethics, George Mason University

REVIEWERSChristine Bechtel, MABechtel Health; National Partnership for Women & Families

Asaf Bitton, MD, MPHBrigham and Women's Hospital & Harvard Medical School

Jean Malouin, MD, MPHUniversity of Michigan

Mary Minniti, BS, CPHQ Institute for Patient- and Family-Centered Care

Bob Phillips, MD, MPAmerican Board of Family Medicine

Sarah Hudson Scholle, DrPH, MPH National Committee for Quality Assurance

Lisa Dulsky Watkins, MDMilbank Memorial Fund Multi-State Collaborative

PCMH MODEL/FRAMEWORK

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ). Patient-centered medical home resource center, defining the PCMH. Retrieved from http://pcmh.ahrq.gov/page/defining-pcmh 7

PCMH EXPANDING RAPIDLY: BUT STILL AN EARLY INNOVATION

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PAYING NOW… OR… PAYING LATER

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PAYMENT REFORM AND MEDICARE

Health & Human Services

• Shift 30% of Medicare FFS payments to value through APMs by 2016, 50% by 2018

• Created of Health Care Payment Learning & Action Network

• Investment in Multi-payer Efforts

Congress

• Passage of Medicare Access and CHIP Reauthorization Act (MACRA)

• Merit-based Incentive Payment System (MIPS)

• Alternative Payment Models (APMs)

10http://doctorwhostories.wikia.com/wiki/The_Macra_Terror_(TS)https://hcp-lan.org/

PAYMENT REFORM & PCMH

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• Fee-for service fails to compensate for PCMH scope of services – esp for small and independent practices• Numerous Alternative Payment Models (APMs) can support PCMH• Evidence does not point to single payment model that best supports

PCMH

Section Two:NEW EVIDENCE FOR PCMH AND INNOVATIONS IN PRIMARY CARE

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#PCMHEvidence

METHODS

INCLUSION CRITERIA• Predictor variable:

– “Medical home”– “PCMH”– “Advanced primary

care”

• Outcome variable:– “Cost” or– “Utilization”

• Date published:– Between Oct 2014

and Nov 2015

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LIMITATIONS• Several reports published this year fall outside

the scope of our inclusion criteria– We track these studies on our PCMH Map

• Does not include studies focused on disease-specific, non-primary care medical homes

• Generally include only the measures that reach statistical significance

• Studies included vary significantly

• DEFINING & MEASURING PCMH REMAINS A CHALLENGE

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RESULTS: TRENDS (n1 = Improvement in measure/n2 = Measure assessed by study)

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DETAILS: Utilization

MEASURES OF UTILIZATION• Emergency department (ED) use

– All cause ED visits– Ambulatory care sensitive

condition (ASCS) ED visits– Non-urgent, avoidable, or

preventable ED visits– ED utilization

• Hospitalization– All cause hospitalizations– ACSC in-patient admissions– In-patient days

• Urgent care visits• Readmission rate• Specialist visits

– Ambulatory visits for specialists

“ED USE” (Peer reviewed studies n=17)• Studies below reported on “ED use”

– 13 measures were ED use reductions, 1 measure was ED use increase

– California Health Care Coverage Initiative

– CHIPRA Illinois study

– Colorado Multi-payer PCMH pilot

– Medicare Fee-For-Service NCQA study

– Pennsylvania Chronic Care Initiative

– Rochester Medical Home study

– UCLA Health System study

– Texas Children’s Health Plan

– Veterans Affairs PACT study (AJMC) • Reported higher ED use for one measure,

and ACSC hospitalizations per patient16

DETAILS: Cost

MEASURES OF COST

• Total cost of care – Net or overall costs– Total PMPM spend– Total PMPM for pediatric

patients– Total PMPM for adult patients

• Total Rx spending• ED payments per beneficiary • ED costs for patients with 2 or more

comorbidities• PMPM spending on inpatient• Inpatient expenditures (PMPY)• Outpatient expenditures (PMPY)• Expenditures for dental, social, and

community based supports

“TOTAL COST” (Peer reviewed, n=17)

• Studies below reported “Total cost of care”– 10 measures were total cost of care

savings, one measure was no net savings– Geisinger Health System PCMH– Blue Cross Blue Shield of Michigan

Physician Group Incentive Program (Health Affairs)

– Blue Cross Blue Shield of Michigan Physician Group Incentive Program (Medical Care Research & Review)

– Colorado Multi-payer PCMH pilot • No net savings over 2 year study

– Pennsylvania Chronic Care Initiative (American Journal of Managed Care)

– UCLA Health System study– Vermont Blueprint for Health

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REFERENCE: Rosenthal, M.B., Alidina, S., Friedberg, M.W., Singer, S.J., Eastman, D., Li, Z., & Schneider, E.C. (2015). A difference-in-difference analysis of changes in quality, utilization and cost following the Colorado Multi-Payer Patient-Centered Medical Home Pilot. Journal of General Internal Medicine. DESCRIPTION: Authors conducted difference-in-difference analyses evaluating 15 small and medium-sized practices participating in a multi-payer PCMH pilot. The authors examined the post-intervention period two years and three years after the initiation of the pilot.

DETAILS BY STUDY

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Section Three: DISCUSSION OF FINDINGS AND

IMPLICATIONS

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#PCMHEvidence

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KEY FINDING

• CONTROLLING COSTS BY PROVIDING THE RIGHT CARE

– POSITIVE CONSISTENT TRENDS:

• By providing the right primary care “upstream,” we change how care is used “downstream”

• Consistent reductions in high-cost (and many times avoidable) care, such as: emergency department (ED) use and hospitalization, etc

• Cost savings evident – but assessment of total cost of care required (while assessing quality, health outcomes, patient engagement, & provider satisfaction)

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WHY DO

SOME

MEDICAL

HOMES WORK

WHILE OTHERS

DON’T?

KEY FINDING

• ALIGNING PAYMENT AND PERFORMANCE

– BEST OUTCOMES FOR MULTI-PAYER EFFORTS:

• Most impressive cost & utilization outcomes among multi-payer collaboratives with incentives/performance measures linked to quality, utilization, patient engagement, or cost savings … more mature PCMHs had better outcomes

• No single best payment model emerged, but extended beyond fee-for-service

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Trajectory to Value-based Purchasing:PCMH part of a larger framework

HIT Infrastructure: EHRs and population health management tools

Primary Care Capacity: PCMH or advanced primary care

Care Coordination: Coordination of care across medical neighborhood & community supports for patient, families, & caregivers

Value/ Outcome MeasurementReporting of quality, utilization and patient engagement & population health measures

Value-Based Purchasing: Reimbursement tied to performance on value

Source: THINC - Taconic Health Information Network and Community

Alternative Payment Models (APMs):

Supporting ACOs, PCMH, & other value

based arrangements

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APM FRAMEWORK WORK GROUP

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Category 1

Fee for Service –

No Link to

Quality & Value

Category 2

Fee for Service –

Link to

Quality & Value

Category 3

APMs Built on

Fee-for-Service

Architecture

Category 4

Population-Based

Payment

A

Foundational Payments for

Infrastructure & Operations

B

Pay for Reporting

C

Rewards for Performance

D

Rewards and Penalties

for Performance

A

APMs with

Upside Gainsharing

B

APMs with Upside

Gainsharing/Downside Risk

A

Condition-Specific

Population-BasedPayment

B

Comprehensive

Population-Based

Payment

Population-Based Accountable APMs

• The LAN’s Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group was successful in developing a Framework for categorizing APMs.

• Within the APM framework, population-based-payment models fall into categories some of 3 and 4.

MACRA – MIPS & APMSProviders Must Choose FFS + PFP1 or Accountable Care

Source: Medicare Access and CHIP Reauthorization Act of 2015; Advisory Board research and analysis.PATEL, KAVITA, APA Presentation, November 2015

1. Pay for performance.2. Value-based payment modifier. 3. Positive adjustments for professionals with scores above the benchmark may be scaled by a factor of up to 3 times the negative adjustment

limit to ensure budget neutrality. In addition, top performers may earn additional adjustments of up to 10 percent. 4. APM participants who are close to but fall short of APM bonus requirements will not qualify for bonus but can report MIPS measures and

receive incentives or can decline to participate in MIPS.

Merit-Based Incentive Payment System (MIPS)

Advanced Alternative Payment Models3

2020: -5% to +15%2

at risk

2019: Combine PQRS, MU & VBPM programs: -4% to +12%2 at risk

2022 and on: -9% to +27%2 at risk

2021: -7% to +21%2

at risk

2018: Last year of separate MU, PQRS, and VBPM2 penalties

2015:H2 – 2019: 0.5% annual update 2026 and on: 0.25% annual update

2020 – 2025: Frozen payment rates

2019 - 2024: 5% participation bonus

2019 - 2020: 25% Medicare revenue requirement

2021 and on: Ramped up Medicare or all-payer revenue requirements

2026 and on: 0.75% annual update

2015:H2 – 2019: 0.5% annual update 2020 – 2025: Frozen payment rates

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MULTI-PAYER COLLABORATIVES:Beyond early evaluations

COMPREHENSIVE PRIMARY CARE INITIATIVE (CPC)

• 5 out of 7 regions reported cost and/or utilization improvements

• Arkansas

• Colorado

• Hudson Valley New York

• New Jersey

• Oregon

MULTI-PAYER ADVANCED PRIMARY CARE DEMONSTRATION (MAPCP)

6 out of 8 MAPCP states found cost and/or utilization improvements

• Michigan

• Pennsylvania

• New York

• North Caroline

• Rhode Island

• Vermont

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KEY FINDING

ASSESSING AND PROMOTING VALUE

– BETTER MEASURES & DEFINITIONS:

• Variation across study measures -- and PCMH initiatives – make for challenging evaluations and expectations (patients, providers, payers)

TRANSFORMING CLINICAL PRACTICE INITIATIVE GOALS

SELECT PCPCC TCPI GOALS

– Define and support patient-practice partnerships

– Promote clinic-to-community linkages

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SAVE THE DATES– Safety Net Medical Home Grantee Symposium (CareFirst

BlueCross BlueShield of Maryland, co-hosted by PCPCC)

• March 15, 2016; 9:00am – 3:00pm

• The Newseum, 555 Pennsylvania Ave NW, Washington, DC 20001

– PCPCC’s March National Briefing webinar• Thursday, March 31st at 1:00pm ET

• “The Primary Care Imperative: New Evidence Shows Importance of Investment in Patient-Centered Medical Homes” (Authored by National Business Group Health and the PCPCC)

– National Medical Home Summit (Co-hosted by the PCPCC)

• June 6 & 7th

• Grand Hyatt, Washington DC

– Celebrate the PCPCC’S 10 year Anniversary – Annual Meeting & Awards Dinner• November 9th and 10th, Grand Hyatt, Washington DC

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alerts, or support our efforts as by becoming executive member at:

www.pcpcc.org